Provider Demographics
NPI:1104490143
Name:HILLRISE PHARMACY LLC
Entity type:Organization
Organization Name:HILLRISE PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OMOTAYO
Authorized Official - Middle Name:OLUFEMI
Authorized Official - Last Name:BADEJOKO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-403-7300
Mailing Address - Street 1:7817 CHELTENHAM AVE
Mailing Address - Street 2:
Mailing Address - City:LAVEROCK
Mailing Address - State:PA
Mailing Address - Zip Code:19038-7621
Mailing Address - Country:US
Mailing Address - Phone:484-326-1877
Mailing Address - Fax:267-335-3937
Practice Address - Street 1:4240 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-1908
Practice Address - Country:US
Practice Address - Phone:215-403-7300
Practice Address - Fax:267-335-3937
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-14
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103114017Medicaid